Koichi Kishimoto

Percutaneous cryoablation of renal cell carcinoma guided by horizontal open magnetic resonance imaging

Background:  Cryoablation is a treatment option for some patients with small exophytic lesions of the kidney. The purpose of this study is to determine the feasibility, safety, and intermediate‐term treatment outcome of percutaneous cryoablation of renal cell carcinoma guided by horizontal open magnetic resonance imaging (MRI).

Flutamide-induced hepatic dysfunction in relation to steady-state plasma concentrations of flutamide and its metabolites

The frequency, severity, and outcome of flutamide-induced hepatic injury were prospectively evaluated in 55 patients with prostate cancer who received 125 mg of flutamide 3 times a day (daily dose: 375 mg) combined with an agonistic analogue of luteinizing hormone-releasing hormone. In addition, we examined plasma and urine concentrations of flutamide and its major metabolites 4 weeks after the beginning of flutamide therapy, and evaluated their significance in predicting flutamide-induced hepatic dysfunction. Hepatic function could be assessed in 50 patients and hepatic dysfunction during therapy was observed in 9 patients (18%); 3 patients (6%) were classified as having moderate liver dysfunction and 6 (12%) were classified as having mild liver dysfunction. The steady-state plasma levels of flutamide and its biologic active metabolite, hydroxyflutamide (OH-Flu), were not related to hepatic dysfunction. However, the concentration of another major metabolite, 4-nitro-3-(trifluoromethyl)phenylamine (FLU-1) was considerably higher in 2 patients who developed clinically significant hepatic dysfunction. These findings suggest that clinically significant hepatic dysfunction could be induced in patients with compromised flutamide metabolism, which leads to a high concentration of FLU-1. Based on results of this study, we propose that plasma FLU-1 levels are one of the predictive factors for flutamide-induced hepatic dysfunction. This hypothesis will be confirmed in a large-scale study.

Estimated glomerular filtration rate on postoperative day 1 is associated with renal functional outcome after percutaneous renal cryoablation for renal tumors

DOI: 10.1111/iju.13361 The incidence of SRMs increases mainly because of the widespread use of cross-sectional imaging. RN has historically been the “gold standard” in these cases, but has been shown to carry an increased risk of CKD and cardiac events compared with PN. Numerous studies have shown that PN is equally effective in the treatment of SRMs, but also technically challenging. Now PCA is a treatment option for patients with SRMs, especially for those who are advanced in age and have comorbidities. However, little is known about the accurate predictors of renal function after PCA. We retrospectively analyzed the medical records of 113 patients who underwent PCA for renal masses, from September 2011 to December 2015, at Jikei University Kashiwa Hospital, Chiba, Japan. All patients had a clinical diagnosis of RCC based on imaging studies. Patients with an insufficient follow up of <6 months and those who underwent PCA for recurrent tumors after cryoablation were excluded; the remaining 73 patients formed the study population. PCA was carried out using an argon-based cryoablation system (CRYO-HIT; Galil Medical, Yokneam, Israel), as previously described. Renal functional outcome was assessed by eGFR, calculated using the Modification of Diet in Renal Disease equation. The percentage of eGFR was calculated in the same manner (%eGFR, postoperative eGFR / preoperative eGFR 9 100). Postoperative eGFR measurements were segregated and stratified into three terms: early (postoperative day 1), intermediate (from 4 to 12 weeks) and late phases (from 16 to 48 weeks), respectively. If a patient had multiple eGFR measurements within one term, the mean value was used. The postablation %eGFR in each phase was compared with preoperative %eGFR by using the Wilcoxon signed rank test. To evaluate the predictors of %eGFR in the late phase, univariate and multivariate linear regression models were used. Variables with a P-value <0.10 on univariate analysis were included in the multivariate analysis. For subset analyses, the transition of %eGFR was compared between the CKD (baseline eGFR <60 mL/min/1.73 m) and non-CKD (eGFR ≥60 mL/min/1.73 m) by repeated measures ANOVA. The differences between CKD and non-CKD were calculated by the Mann–Whitney U-test, or the v-test. The median age at the time of ablation was 70 years (range 62–77). The mean size of the tumor was 29.8 10.2 mm. The mean preoperative eGFR was 58.7 17.5 mL/min/1.73 m (Table S1). Postablation changes in %eGFR are shown in Figures 1a and S1a. The mean %eGFR in the early phase was 88.8 11.7; significantly lower when compared with the baseline value (P < 0.0001). The mean %eGFR in the intermediate and late phases was 90.4 13.7 and 89.8 10.6, which were also significantly lower than the preoperative value (P < 0.0001). These findings show that the impairment of renal function plateaued after day 1, and no recovery was observed thereafter. Univariate and multivariate analyses were carried out to identify perioperative predictive factors for the long-term renal functional outcome. The %eGFR in the early phase was found to be the only independent predictor (P < 0.0001; Table S2). Of the 73 patients, 35 were stratified into CKD and 38 into nonCKD groups, respectively (Table S1). No significant difference in the patterns of transition in renal function was observed between the groups (P = 0.987), and renal function did not recover after postoperative day 1 in either group (Fig. 1b,c; Fig. S1b,c). Several studies have reported functional outcomes of renal cryoablation, concluding that renal change after cryoablation was minimal and clinically unimportant. However, the present results suggest that renal function after PCA was significantly impaired in the early phase, and did not recover thereafter. One of the factors responsible might be the limited observation period. The present study might not be long enough to confirm recovery of renal function. However, no patients developed severe CKD requiring hemodialysis to date. Such a decline might be considered an acceptable trade-off in consideration of disease burden. The present study was not devoid of limitations. These included its retrospective nature – a single institutional experience. The number of patients matched in the present study was not

Digestive Tract Complications of Renal Cryoablation

We report a case each of duodenorenal and colorenal fistula that arose after computed tomography-guided percutaneous cryoablation (PCA) for renal cell carcinoma and use imaging and endoscopic findings to analyze their causes and mechanisms. Both complications occurred though the edge of the iceball did not touch the intestinal wall, and patients’ symptoms and fistula formation occurred several days after the PCA procedure. Based on imaging and endoscopy findings, we suspected the colorenal fistula resulted from bowel injury caused by ischemia from the occlusion of small vessels at the procedure’s low temperature. Both cases were resolved conservatively without surgical intervention.

Anatomical localization and clinical impact of sentinel lymph nodes based on patterns of pelvic lymphatic drainage in clinically localized prostate cancer

Although sentinel lymph node in prostate has been generating renewed interest, its significance remains controversial due to inadequate evidence.

Improved technique for intracorporeal neobladder-urethral anastomosis in laparoscopic radical cystectomy

DOI: 10.1111/iju.13299 In an attempt to reduce morbidity of ORC, minimally-invasive surgery such as LRC and RARC have been assessed for their safety and feasibility, confirming reduced blood loss, decreased postoperative pain and quicker recovery after surgery. RARC is increasingly being carried out worldwide, but LRC has seen only limited adoption because of its technical difficulties. LRC has gained popularity more recently in Japan, because RARC is not currently covered by the public healthcare system. Although total intracorporeal diversion in RARC has been increasingly advocated in a few high-volume centers, extracorporeal urinary diversion is more acceptable in RARC and LRC because of its lower complexity. We also consider that extracorporeal urinary diversion through a minilaparotomy is reasonable, because an extension of the port incision is ultimately necessary for specimen removal, and the procedures are equivalent to those for the open technique, thus reducing operating time but still maintaining the advantages of minimally-invasive surgery. Here, we report a novel procedure, a temporary pulling suture technique, to facilitate intracorporeal NB-urethral anastomosis, which still remains most difficult and challenging in this complex surgery. We retrospectively reviewed 30 cases of LRC with extracorporeal NB by a single surgeon between April 2009 and July 2015. The patients were stratified into two groups. Our temporary pulling suture technique was not used in the first 15 patients, but was used in the last 15 patients. Studer’s NB and ureterointestinal anastomosis were constructed extracorporeally after laparoscopic cystectomy and extended pelvic lymph node dissection. In group 1, the NBurethral anastomosis was carried out intracorporeally using four interrupted sutures. In group 2, we applied modification, a temporary pulling suture technique, to facilitate intracorporeal NBurethral anastomosis as described below. Before the NB was placed in the pelvis, a 75-cm 3-0 monofilament polyglyconate suture was securely and deeply applied in order not to make the wall of the NB neck tear, but not tied, at the 5 o’clock position of the NB neck, and a loop was created with the suture. The end of the looped suture was fixed to the tip of the Foley catheter, which was inserted retrogradely through the urethra and brought over the abdominal incision (Fig. 1a). The NB was then placed back into the pelvis and pneumoperitoneum was restarted. The NB was brought down closer to the urethral stump by gently pulling out the Foley catheter to guide and stabilize the NB neck (Fig. 1b,c). By pulling and moving the suture, the NB neck was easily identified and clearly visualized. The initial laparoscopic stitch for anastomosis was placed at the urethra and the NB neck at the 4–6 o’clock position. The looped suture was held with appropriate tension during anastomosis with four interrupted sutures in the first 10 cases or running sutures in the latter five cases. Subsequently, the looped suture was cut, pulled and removed from the patient’s urethra without any difficulty. Our temporary pulling suture technique is included as Supporting Information (Video S1). Group 2 merited significantly reduced time for NB-urethral anastomosis (77 25 vs 37 9 min, P = 0.001). No difference was found regarding time for urinary diversion excluding NB-urethral anastomosis (148 37 vs 134 19 min, P = 0.21). One patient developed urethral anastomotic stricture only in group 1. Daytime and night-time continence rates at 6 months postoperatively between group 1 and group 2 were 73% versus 80%, and 52% versus 60%, respectively; there were no differences between the two groups. The operative outcomes are shown in Table S1. Laparoscopic NB-urethral anastomosis is technically challenging. First, anastomotic and mesenteric tension exist when the NB is placed down to the urethral stump without handguided assistance (Fig. 1d). Second, there is insufficient visualization of the anastomotic site and the instability of the NB itself compared with the native bladder. Our temporary pulling suture technique is helpful for identification and stabilization of NB, and providing clear vision of the anastomotic site without excessive tension. We have not experienced any disadvantages, such as laceration of the NB neck, during this procedure. In fact, our novel techniques considerably shorten operating times for NB-urethral anastomosis without any adverse functional results.

A CASE OF ADENOCARCINOMA OF THE EPIDIDYMIS WITH HYDROCELE

A 72-year-old man presented with left scrotal swelling. The patient was diagnosed with left testicular hydrocele and underwent the hydrocele aspiration. However, it recurred within a short period. Magnetic resonance imaging (MRI) revealed a tumor in the epididymis and the patient then underwent left high orchiectomy. The histopathological examination revealed an adenocarcinoma of the epididymis. Ten months after the surgery, the patient has been free of disease.

Shrinkage of Prostate Volume in Sunitinib-treated Patients with Renal Cell Carcinoma

Sunitinib is widely used to treat patients with advanced renal cell carcinoma; however, its influences on the prostate volume and lower urinary tract symptoms remain unclear. To investigate the influence of sunitinib on clinical findings of urinary tract, we recruited a total of 20 male patients with advanced renal cell carcinoma who are treated with sunitinib. We evaluated clinical findings during clinical visits over 24 weeks: International Prostate Symptom Score, urine flow rate, residual urine volume, serum prostate-specific antigen level and prostate volume. Residual urine and prostate volumes were significantly decreased at Week 24. The residual urine volume was especially decreased in patients with a high residual volume at baseline. No differences were observed in the International Prostate Symptom Score total score, International Prostate Symptom Score quality of life score, maximal urinary flow rate or prostate-specific antigen level. We observed a reduction in prostate volume and an improvement in urinary symptoms through relief from urinary tract obstruction during sunitinib treatment. Careful attention to urinary functions and drug dose adjustment seems to be necessary in patients with comorbid benign prostatic hyperplasia or dysuria.

Percutaneous cryoablation for stage T1b renal cell carcinoma in a patient with horseshoe kidney

We report the first case of percutaneous cryoablation (PCA) for stage T1b renal cell carcinoma (RCC) in a horseshoe kidney (HK). A 76-year-old man with an HK underwent computed tomography-guided PCA for RCC measuring 42 mm (stage T1b) in diameter. Although transcatheter embolization before the PCA and hydrodissection were required to avoid complication and incomplete ablation, PCA was successfully performed without complication. The complete ablation was confirmed on computed tomography images 1 month after the procedure. There was no recurrence or metastasis during 2 years of follow-up. We believe this is the first report of PCA for stage T1b RCC in a patient with HK. This technique can be performed without regard to tumor size and location and may be considered as a treatment option to avoid complex surgery.